Innovations
Transitioning Home Post-Hospital: Collaborative Project to Support Older Adult Transitions
2014 NICHE Conference Poster. Authors: Joanne Grosh, RN, MA; Lisa Senawi, RN, MSN; Andrea Gossett Zakrajsek, OTD, MS, OTRL & Elizabeth Schuster, PhD, Chelsea Community Hospital/Saint Joseph Mercy Health System and ChelseaCare Home Health.
These facilities formed a community research partnership to explore and support transitions of older adults through the healthcare system, specifically from a hospital stay to home with rehabilitative services. The team used a participatory action research approach that included:
- Observation of home health sessions between service providers and older adults
- In-depth interviews of home health service providers
- In-depth interviews of older adults receiving home health service
Research Findings
Barriers to Care Transitions
- Communication: Breakdown in information exchange between providers and patients, and among service providers
- Challenges in Returning Home: Negotiating the physical environment in the home and community, specifically falls and giving up value-added activities
Key Supports
- Overcoming environmental barriers (i.e. ramps, mobility devices)
- Regaining confidence and changing perception of ability to re-enter the community
- Family, friends, other caregivers facilitating successful transitions
Actions Based on Research Findings
- System to enhance communication between service providers and older adults
- Handouts and pamphlets to facilitate communication
- List of useful questions for patients to ask and advice for patients regarding care transitions
View the conference poster
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